HomeMy Public PortalAbout6343 SALTER AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
sure, or a certificate of Workers' Compe ration Insurance,
inHEATING - VENTILATING - AIR CONDITIONING
in a certified copy thereof(Sec. 3800, Lab,•t.) 76A364C _
20-0046 DPW 9/86
Policy No. " Company
F-1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ���
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY,�-C� LEC--I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. c�F
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars(;100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM `
permit is issued, I shall not employ any person in any manner I
so as to become subject to the Workers'Compensation Laws. I BOILER, BTU APPROVALS DATE INSPECrOR'S SIGNATURE
Date Applicant r COMPRESSOR, BTU 36 i �' �� ROUGH
NOTICE O�T: If, after making 1his Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA DAT
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAUGRAILITY
I LICENSED'CONTRACTORS DECLARATION FLOOR TU ( ,
I hereby affirm that I am:licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— LF °l!'
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. ER-4'OR
License NumberiT � � Lic. Class3307 –°'
U
Contracto3 Im
❑ I am exempt under Sec. Ai.Ci .a U
Plan check fee 33.07 37.!312
B.&P.C. for this reason PERMIT ISSUING FEE$
-Data:—
d d) ITEMS Z
a: I
Signature TOTAL FEE Ov TO iAL 37.00
OWNER-'BUILDER DEC RATION PLAN CHECK APPLICANT CHECK
37.00
I hereby affirm that,I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAM t I CHANGE, °il�
Professions Code):
El 1, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation,will do the work andCln / TEL
the structure is not.intended or offered for sale(Section L (��. ~
7044, Business and Professions Code). OWNER Toss 1 AM10=16
❑ L �Q
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY r ( TEL.N9
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTO Vl��
(Sec. 3097, Civ. C.).
ADDRESS Q 1 /�
Lender's Name
CITY �,>s✓ TEL. N ` ? &14,11J
Lender's Address
I certifythat I have read this application and state that the STATE �p LIC.
pp LICENSE NO.�.-� i C7 V y CLASSr�
above information is correct. I agree to comply with all County �•
ordinances and State laws relating to building construction, ;
an er by authoriz epresentatives of this County to enter
on a above-me i e property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE _
I
Da
Signature.of Applicant or Agent e